Pittman Hernández DA.

(2016) The association between maternal self-report of depression and the risk of pre-eclampsia:
outcome data from 960 participants in a retrospective case-control study. Evidence Based Midwifery 14(3): 76-81

The association between maternal self-report of depression and

the risk of pre-eclampsia: outcome data from 960 participants
in a retrospective case-control study
Daniela A Pittman Hernández MLA.
Associate professor, IE University, Calle María de Molina, 31 BIS, 28006 Madrid Spain. Email: danielapittman@post.harvard.edu

This research was supported in part by the award for the dean’s prize for outstanding thesis in the Behavioral Sciences at Harvard University in May 2010. The author
would like to thank her thesis advisor, Dante Spetter Phd. The author is also very grateful to the Preeclampsia Foundation for hosting the online questionnaire on its
website. For additional tables, visit rcm.org.uk/ebm

Abstract
Background. Eclampsia, the occurrence of a seizure in association with pre-eclampsia (PE), remains an important cause of
maternal mortality. While it has been suggested that altered excretion of vasoactive hormones in women with depression may
increase PE risk, there are no data specifically addressing this issue. Furthermore, the mechanisms that may link depression,
specifically a history of major depressive disorder (MDD) prior to pregnancy, with an increased PE risk are unknown.
Aim. To test the hypothesis that women with a history of depression and/or women who experience depressive symptoms for
the first time during pregnancy have a higher risk of developing PE as a pregnancy complication.
Method. To investigate this possible association, 960 women participated in an online survey designed to identify any
relationship between depressive symptoms prior to and throughout pregnancy and the development of PE.
Results. A history of depression is associated with a 2.2-fold increased risk (OR 2.2, 95% CI 1.1, 5.4) for the development of
PE; meaning that out of the 438 women in the study who experienced PE, 124 of the women had been diagnosed by a medical
doctor with MDD prior to pregnancy. Furthermore, the results demonstrate that women presenting depressive symptoms
during pregnancy, specifically women reporting daily psychological stress during pregnancy, are associated with a 3.5-fold
increased risk (OR 3.5, 95% CI .45, .69) for PE outcomes. Also, women who endure anxiety on a frequent or daily basis were
associated with a 1.7-fold increased risk (OR 1.7, 95% CI .43, .73) for subsequent PE outcomes.
Conclusion. This study highlights the importance of detecting MDD both prior to, and during, pregnancy not only to support
the mother’s mental health, but also to prevent the possible complications of PE.

Key words: Depression, pre-eclampsia, pregnancy, self-reporting, retrospective case-control study, evidence-based midwifery

Background 44 years which, coincides with the prime childbearing years

Major depressive disorder (MDD) is considered to be an
important health problem in modern societies, with women
twice as likely to be affected as men (Epperson, 1999).
The Diagnostic and statistical manual of mental disorders
(DSM-4) defines it as depressed mood or a loss of interest
or pleasure in daily activities for more than two weeks,
accompanied by mood changes that must represent a change
from the person’s baseline; accompanied with impaired
function (social, occupational, educational) (American
Psychiatric Association, 2000). Consistent with the DSM-4,
at least five of the following nine specific symptoms need to
be present nearly every day to be diagnosed with MDD:
• Depressed mood or irritable most of the day, nearly every
day, indicated by subjective report or observation
• Decreased interest or pleasure in normally pleasureable
activities, most of each day (anhedonia)
• Significant weight change (5%) or change in appetite
• Change in sleep – insomnia or hypersomnia
• Change in activity – psychomotor agitation or retardation
• Fatigue or loss of energy
• Guilt/worthlessness – excessive or inappropriate
• Lack of concentration – diminished ability to think or
concentrate, indecisiveness
• Suicidality – thoughts of death/suicide, or has suicide plan.
An estimated 20% of US women develop MDD in their
lifetimes (Bhatia, 1999). The peak age of in women is 18 to
(Epperson, 1999). Prevalence among pregnant women is
significant, affecting 4% to 16% of all US pregnancies (Misri,
2007). Approximately 25% to 35% of pregnant women
experience depressive symptoms that peak during the first
trimester (Zinga et al, 2005). Elevated levels of depression,
such as experiencing anhedonia in pregnancy, are shown to
be associated with preterm labour (Alder et al, 2007).
Because depressive symptoms mimic pregnancy-
related disturbances, distinguishing whether a woman is
experiencing depression or symptoms of pregnancy can be
challenging (Misri, 2007). MDD may mimic pregnancy-
related symptoms, such as eating or sleeping irregularities,
that may be related to the hormonal changes experienced
during pregnancy. Obstetricians may be especially
challenged in distinguishing depressive symptoms from those
of pregnancy among patients with no history of depression.
Untreated depression during pregnancy is associated with
poor maternal nutrition, as well as increased consumption
of alcohol and poor attendance at prenatal visits, placing
both mother and fetus at risk (Austin, 2006). Several studies
have shown that depression during pregnancy may be a risk
factor for spontaneous abortion (Arck, 2001). Considering
that a history of depression is the strongest indicator for
depression during pregnancy (Bhatia, 1999), the abrupt
discontinuation of antidepressants during pregnancy may
lead to the recurrence of the disorder (Misri, 2007).

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 Pittman Hernández DA. (2016) The association between maternal self-report of depression and the risk of pre-eclampsia:
outcome data from 960 participants in a retrospective case-control study. Evidence Based Midwifery 14(3): 76-81
Pre-eclampsia
Pre-eclampsia (PE), leading to eclampsia, is a potentially life-
threatening condition that only occurs during pregnancy,
typically after the 20th week of gestation (Sibai, 2008).
Affecting over four million women worldwide, PE is
responsible for around 76,000 deaths each year (Lyall and
Belfort, 2007). Currently, PE can only be detected far into
pregnancy, and it is diagnosed when both hypertension
and proteinuria are present (Sibai et al, 2005). To date, no
predictive test exists to identify women who will subsequently
develop PE (Huppertz, 2008). Annually, PE affects 5% to
8% of pregnancies globally (Lyall and Belfort, 2007).
The condition is associated with significant prematurity
and all of its associated complications, including admission
to neonatal intensive care. Proper prenatal care is essential
to diagnose and manage PE. Substandard prenatal care,
including failure to diagnose the condition, may lead to death
(Ceron-Mireles et al, 2001). Symptoms associated with the
pregnancy-induced disease include: swelling, sudden weight
gain, headaches and changes in vision (Lyall and Belfort,
2007). However, some women with rapidly advancing
disease experience few symptoms (Sibai et al, 2005).
Currently, there is no available cure for the condition, apart
from timely delivery of the baby and, more importantly, of
the placenta (Huppertz, 2008).
Risk factors for developing PE include previous personal
and family history of PE, multiple gestation, maternal
age (over 40 or under 18) obesity – women with greater
than 30% body mass index (BMI) (Sibai et al, 2005).
Predisposing factors for PE that are also risk factors for
other endothelial conditions, particularly diabetes, include
history of hypertension, increased insulin resistance,
increased testosterone and increased blood homocysteine
concentration (Roberts and Cooper, 2001).
Recent research found that genetic, environmental
and socioeconomic risk factors already established
before conception play a key role in the development of
cardiovascular disease later in life, and thus may explain
pregnancies complicated by PE as well (Sibai, 2008). One
study examined the effect of cardiovascular risk factors
before pregnancy among the risk of PE outcomes in 3494
women. Among respondents, 8.8% developed subsequent
PE. Based on positive associations between cholesterol levels,
serum levels of triglycerides, pre-pregnancy baseline systolic
blood pressure and low-density lipoprotein cholesterol, the
authors concluded that women with pre-pregnancy risk
factors for cardiovascular disease are predisposed to PE
(Magnussen et al, 2007).
Pre-existing maternal conditions associated with coronary
disease, such as hypertension and diabetes, increase the
risk for the disease (Roberts and Cooper, 2001). Likewise,
studies show that women who have experienced PE are at
higher risk for developing diabetes and hypertension later in
life (Ness and Roberts, 1996).
Evaluation of modifiable risk factors, such as work-
related psychological stress, should be considered. A case-
control study of 110 first-time pregnant women with PE
compared to 115 primiparity controls, showed women who
© 2016 The Royal College of Midwives. Evidence Based Midwifery 14(3): 76-81
76-81_EBM_122 Pitman.indd 77
worked during pregnancy had a 2.3 times greater incidence
of developing PE. The authors indicated that work-related
psychosocial stress during pregnancy increased the risk of
the condition (Klonoff-Cohen et al, 1996).
Rationale for the present study
This retrospective case-control study examines both a
history of depression and depressive symptoms during
pregnancy with subsequent PE outcomes. This study
examines a history of MDD pre-pregnancy versus the
range of all maternal mood disorders. Furthermore, if
results show that women with a history of MDD prior to
pregnancy are also at a higher risk of developing PE, these
may be implications for treating depression in the months
before conception and for closely monitoring women with
a history of MDD during pregnancy.
Aim
The aim of this study was to determine if pregnant women
with a history of MDD prior to pregnancy are more prone
to develop PE than women without a history of MDD,
in order to clarify the nature of the PE/depression link.
Additionally, this retrospective study investigated whether
women with prenatal history of MDD are at greater risk
of developing PE than women who report depressive
symptoms for the first time during their pregnancy. Finally,
this study evaluated the impact of both the prenatal history
of MDD as well as the depressive symptoms experienced
during pregnancy with PE outcomes, such as preterm birth,
future incidence of PE, and maternal morbidity.
The operant hypothesis was that women with a history of
MDD are more likely to develop PE than women without
a history of MDD. Furthermore, this retrospective case-
control study evaluated if women with a history of MDD
prior to pregnancy hold the same risk level for developing
PE as women who develop depressive symptoms for the
first time during pregnancy. Thus, a history of depression
anytime up to, and during, gestation in women should be
associated with increased PE risk.
Method
The total sample size consisted of 960 previously pregnant
women: 438 participants with PE outcomes (46%) and
522 participants without PE outcomes (54%). All 960
participants completed a 30-question online survey within
a 60-day interval, thus the sample size of 960 was obtained
during this two-month period.
The US-based non-profit Preeclampsia Foundation agreed
to place a link to the survey on its website. The organisation
funds research, raises awareness, and provides support for
those whose lives have been affected by PE. Participants
were recruited through this voluntary survey, which was
open to all primiparous and multiparous women.
An invitation to participate in the survey was also passed
on through Facebook and sent out via emails. All survey
data were collected with informed consent from the
participants and the survey was conducted under the
approval of Harvard University Committee on the Use of
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 Pittman Hernández DA. (2016) The association between maternal self-report of depression and the risk of pre-eclampsia:
outcome data from 960 participants in a retrospective case-control study. Evidence Based Midwifery 14(3): 76-81
Human Subjects in Research. Inclusion criteria for both
groups consisted of a history of a singleton and first-time
pregnancy. Women with the following criteria were excluded
from this study:
• History of current or previous mental disorders, such
as schizophrenia
• History of other pregnancy complications unrelated to
pregnancy induced hypertension, such as placenta previa
• Who could not remember details of their first pregnancy
and/or who were born before 1950.
Measures
An online self-report questionnaire was used to collect
the data from all of the participants. The questionnaire
was used to screen participants regarding the history and
outcomes of their first pregnancy. Data were collected about
socio-demographic characteristics, as well as any history of
depression prior to pregnancy and/or depressive symptoms
during pregnancy, with particular attributes to onset before
or after the 20-week mark. The woman’s age was based on
the time of the delivery of her first baby. Participants with a
history of depression were asked to indicate any treatment
received (such as medication and therapy).
Women were asked for up to a 30-year recall (to the best
of their knowledge) of all of the events that lead to the birth
of their first baby. The majority reported a pregnancy that
they had endured recently, specifically in the past five years.
The online survey was available for 60 days, thus obtaining
a total of 960 sample size. The study started on 23 April
2009 and ended on 24 June 2009.
Procedure
The study was completely voluntary and the heading read:
‘Please join a study by a researcher at Harvard University
examining the relationship between emotional wellbeing
and pre-eclampsia outcomes.’ All of the participants
were directed to a survey link (Zoomerang) from the
Preeclampsia Foundation’s homepage. All participants
read and accepted the consent form at the beginning of
the survey regarding the nature of the study. Once all the
results were obtained, the participants were divided into
two groups: group 1 (PE group): women with PE outcomes
and group 2 (control group): women without PE outcomes.
Most of the PE group were directly recruited through the
Preeclampsia Foundation homepage. Most of the control
group were recruited through Facebook asking them to
fill out the online survey; those participants subsequently
forwarded the same email to their acquaintances. All results
came back anonymous and in an encrypted form and have
been presented in the aggregate. Thus no individual was
identifiable. No inducement was offered.
Statistical analysis
Chi-square tests and student’s t-tests were conducted to test
for associations between the frequencies of the key variables:
socio-demographic, clinical, pregnancy and psychological
characteristics, stress factors and PE outcomes. Based on
multivariate analysis, after adjustment for key variables –
78 © 2016 The Royal College of Midwives. Evidence Based Midwifery 14(3): 76-81
76-81_EBM_122 Pitman.indd 78
hypertension, daily stress, ethnicity, history of depression,
employment status, 40+ age, depressive symptoms during
pregnancy – regression analysis was conducted to compare
results between a history of hypertension, daily psychological
stress, full or partial employment and being Caucasian with
subsequent PE outcomes. Additionally, regression analysis
was used to compare the percentage rates of women who
had never come across depressive issues prior to or during
pregnancy, with percentage rates of women who had
depressive issues either before or during their pregnancies
and subsequent PE rates. Finally, regression analysis was
conducted to evaluate the impact of both the prenatal
history of MDD, as well as the depressive symptoms during
pregnancy with PE outcomes, such as maternal morbidity
and recurrence of PE in future pregnancies.
Results
In Table 1, a chi-square test was conducted to test the socio-
demographic characteristics of the participants. Among the
respondents, the population who developed PE tended to be
from the slightly younger category, ages 20 to 24, χ²=10.01,
p<0.005 – 75 women in this age group developed PE (17.1%)
versus 53 women who did not develop PE (10.2%) – followed
by the 40+ age category, χ²=4.23, p<0.05 – nine developed
PE (2.1%) versus three who did not develop PE (0.6%).
Those least likely to develop PE tended to be from the 30 to
34 age category χ²=15.90, p<0.001 – 117 women developed
PE (26.7%) versus 203 who did not develop the condition
(39.2%). Among the racial categories, higher responses of
PE outcomes came from white/Caucasians, however, 76.0%
of the total sample size were white/Caucasians.
Results indicate that white/Caucasians are most likely to
develop PE, χ²=60.02, p<0.001 – 389 women developed
the condition (86.8%) versus 354 who did not (66.9%)
– while Hispanics are least likely to develop it, χ²=49.58,
p<0.001 – 35 women developed PE (7.8%) versus 132 who
did not develop PE (25.0%). Among the respondents, the
income distribution appeared similar in all of the categories
with a slightly higher response rate of PE outcomes from
the $30,000 to $49,999 salary group, χ²=8.81, p<0.005.
Among the respondents, the marital distribution appeared
similar in all of the categories with a slightly higher
response rate of PE outcomes from the living-as-married
category, χ²=9.40, p<0.005.
Among those who responded, the employment status
distribution was skewed. Results indicate that women
with full-time/part-time jobs are more likely to develop
PE, χ²=33.33, p<0.001. Results indicate that women least
likely to develop PE are self-employed, χ²=13.86, p<0.001;
students/interns, χ²=6.27, p<0.05; and those who are
voluntarily out of the job market, χ²=7.53, p<0.01.
Among the respondents, the population who developed
PE tended to have a history of hypertension, χ²=31.93,
p<0.001, followed by diabetes, χ²=9.20, p<0.005. Women
who took prescription medication prior to pregnancy were
more likely to develop PE than those who did not take such
medication before pregnancy, χ²=30.62, p<0.001.
No significant results between the planned versus the
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 Pittman Hernández DA. (2016) The association between maternal self-report of depression and the risk of pre-eclampsia:
outcome data from 960 participants in a retrospective case-control study. Evidence Based Midwifery 14(3): 76-81

Table 1. PE outcomes of participants (n=960) 4%), than to not develop the condition (eight
women, or 1.5%), and this finding is highly
Women who Women who significant (p<0.001).
developed did not Among the respondents, the category
PE develop PE most likely to develop PE tended to be those
who frequently endured stress during the
PE outcomes n= % n= % pregnancy, χ²=16.68, p<0.001, and those
who endured daily stress, χ²=35.19, p<0.001.
Did you ever develop PE in Yes 100 26.67% 23 4.45%
pregnancy The category least likely to develop PE tended
No 275 73.33% 494 95.55% to be those who never, χ²=15.87, p<0.001,
or rarely, χ²=25.83, p<0.001, endured stress
Total 892 375 100% 517 100% during the pregnancy. Results indicate that
Did you have a preterm Yes 328 75.75%
women with a higher frequency of stress
delivery? during pregnancy are more likely to develop
No 105 24.25% PE than those never or rarely stressed during
pregnancy. Women who rarely or never
Total 433 433 100% endure stress during pregnancy are twice
Did the baby experience
as likely not to develop PE (35.5%) than to
any health complications as develop it (16.5%), and this finding is highly
a coincidence of PE? No 283 46.02% significant, (p<0.001).
Among the respondents who took
Neonatal intensive care unit 190 30.89%
antidepressant medication prior to their
Oxygen therapy 87 14.15% pregnancy, the population who discontinued
their antidepressants during pregnancy was
Severe… to baby’s death 50 8.13% 72.0% more likely to develop PE, compared
to the population who continued their
Severe… to baby’s disabilities 5 0.81%
medication (28.0%).
Total 615 615 100% A chi-square test was conducted to test
the stress factors of participants. Those who
Did you experience any tested positive with anxiety symptoms during
health complications as a pregnancy (on a frequently or daily basis)
coincidence of PE? No 133 22.20% were almost three times as likely to develop
Prolonged hypertension 169 28.21% PE (27.1%) than not to develop it (11.1%)
and this finding is highly significant: anxiety
HELLP syndrome 112 18.70% symptoms during pregnancy on a frequent
basis, χ²=16.23, p<0.001, and anxiety
Eyesight disturbances 91 15.19%
symptoms during pregnancy on a daily basis,
Kidney complications 73 12.19% χ²=21.24, p<0.001.
Additionally, women who tested positive
Eclampsia 21 3.51% with anhedonia during pregnancy on a
frequent or daily basis were twice as likely
Total 599 599 100%
to develop PE (8.8%) than not to develop
it (3.7%).
Furthermore, the population who tended to
unplanned pregnancy categories were found. No significant develop PE tested positive for extreme mood changes on a
results between the modes of conception were found either. daily basis, χ²=10.06, p<0.005, followed by irritability on
A chi-square test was conducted to test the psychological a daily basis, χ²=13.15, p<0.001, where those who were
characteristics of the participants. Among the respondents, least likely to develop PE tended to be from the excessive
the population least likely to develop PE tended to be those crying category.
who did not endure a significant life event the year before A student t-test was conducted to test the frequency
conception, χ²=7.55, p<0.01, nor during the pregnancy, of future PE outcomes of the participants. Among the
χ²=9.51, p<0.005. respondents, women who developed PE were 26.7% more
Respondents diagnosed with depression prior to likely to develop the condition in a future pregnancy.
pregnancy were more likely to develop PE, χ²=29.97, Based on multivariate analysis, after adjustment for
p<0.001, as were respondents diagnosed with depression key variables (history of hypertension, daily stress during
during pregnancy, χ²=5.22, p<0.05. Specifically, women pregnancy, ethnicity, history of depression, employment
diagnosed with depressive symptoms during pregnancy status, 40+ age, depressive symptoms during pregnancy),
were twice as likely to develop PE outcomes (17 women, or results indicate that a history of hypertension is associated

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 Pittman Hernández DA. (2016) The association between maternal self-report of depression and the risk of pre-eclampsia:
outcome data from 960 participants in a retrospective case-control study. Evidence Based Midwifery 14(3): 76-81
with a 9.5-fold increase risk (OR 9.1, 95% CI .05, .10) for
subsequent PE outcomes. Furthermore, the results indicate
that daily psychological stress is associated with a 3.5-fold
increase risk (OR 3.5, 95% CI .45, .69), history of depression
is associated with a 2.2-fold increased risk (OR 2.2, 95% CI
1.1, 5.4) full or partial employment (OR 2.0, 95% CI .80,
.34) and being Caucasian (OR 3.1, 95% CI .16, .26) for
subsequent PE outcomes.
Discussion
Based on multivariate analysis, a history of depression is
associated with a 2.2-fold increased risk (OR 2.2, 95% CI
1.1, 5.4) for subsequent PE outcomes. The first hypothesis
proposing that women with a history of depression would
be more prone to develop PE than women without a history
of depression was supported. The result of this finding is
a major implication for treating depression in the months
prior to conception and for closely monitoring women with
a history of MDD during pregnancy.
Furthermore, results demonstrate that women presenting
depressive symptoms during pregnancy, specifically women
reporting daily psychological stress during pregnancy, are
associated with a 3.5-fold increase risk (OR 3.5, 95% CI
.45, .69) for PE outcomes, followed by women who endure
anxiety on a frequent or daily basis, associated with a
1.7-fold increased risk (OR 1.7, 95% CI .43, .73) for PE
outcomes. Hence, the second hypothesis proposing that
women who develop depressive symptoms for the first time
during pregnancy will be more prone to develop PE than
the non-depressive group, is also supported. Consistent with
this finding other authors have found that work-related
psychosocial stress during pregnancy increased the risk of
PE (Klonoff-Cohen et al, 1996).
Depressive symptoms during pregnancy, specifically levels
of anxiety on a frequent and/or daily basis, were found to be
highly associated to subsequent PE outcomes. The author’s
findings are consistent with Qiu et al (2007), confirming that
there is a positive relationship between depressive symptoms
during pregnancy and PE outcomes. Additionally, women
who tested positive with anhedonia during pregnancy on a
frequent or daily basis were twice as likely to develop PE
(8.8%) than not to develop it (3.7%). This finding is also
highly significant: anhedonia on a frequent basis, p<0.05,
and anhedonia on a daily basis, p<0.05.
Hence, these findings support the hypotheses that both
women with a history of depression and women who
experience depressive symptoms during pregnancy have a
higher risk of developing PE as a pregnancy complication.
This study highlights the importance of detecting MDD
prior to and during pregnancy, not only to support the
mother’s mental health, but also to evaluate the possible
complications of PE.
Through this study, other related variables were found to be
associated with PE outcomes. Women taking antidepressant
medication during pregnancy tended to develop less PE
than the population of women who stopped taking the
antidepressants during pregnancy. Among the respondents
who took antidepressant medication prior to pregnancy, the
80 © 2016 The Royal College of Midwives. Evidence Based Midwifery 14(3): 76-81
76-81_EBM_122 Pitman.indd 80
population who discontinued their antidepressants during
pregnancy was 72% more likely to develop PE, compared
to the population who continued their medication during
pregnancy (28%). This association is highly significant,
suggesting that women with a history of depression and
who have been prescribed antidepressant medication should
continue to do so during pregnancy, not only to help with the
depressive symptoms, but also to prevent the development
of subsequent PE. Women who decide to remain on their
antidepressant medication throughout their pregnancy are
not only protecting themselves from depression, anxiety and
stress symptoms, but are also reducing the risk of developing
PE and all of its related complications for both mother and
infant. It follows then the possibility that antidepressants may
work not only as a protective factor for high levels of stress,
but also as a protective factor for the development of PE.
Future studies must weigh the risks versus the benefits that
highlight the importance of antidepressant therapy during
pregnancy as a protective barrier to the development of PE.
As with all medical use during pregnancy, there are a
number of risks and benefits to both the mother and the fetus
that must be taken into consideration. There are a number
of unknowns and it is sometimes difficult to distinguish
between the effects of the treatment and the effects of the
condition itself. Among the respondents, the population
who developed PE tended to have a history of hypertension.
Similar to PE, hypertension is also referred to as a ‘silent
disease’ because individuals are usually unaware of it until
severe organ damage occurs (Irminger et al, 2008).
The author’s finding is consistent with other studies,
indicating that a history of hypertension may be a
predisposing risk factor for PE (Roberts and Cooper,
2001). It is not surprising that the presence of hypertension
can trigger vascular abnormalities in women with other
predisposing risks for PE. It has been suggested that altered
excretion of vasoactive hormones in women with depression
may increase the risk for PE (Bonari et al, 2004). When
multiple risk factors are working at the same time, the
chances of developing PE are probably greater than women
without any history of hypertension. Future studies are
needed to clarify the exact mechanisms linking these two
factors together.
Limitations
The lack of medical records and the reliance upon self-
reports regarding a clinical diagnosis of MDD both prior
and during pregnancy is a major limitation of this study.
Social desirability, specifically not acknowledging that one
may be depressed, during pregnancy at what should be a
‘happy’ period may contribute to under-reporting of the true
incidence of MDD. The biggest challenge with self-report
tests is that participants may exaggerate symptoms in order
to make their situations seem worse, or they may under-
report the frequency of symptoms in order to minimise their
problems (Northrup, 1996).
Furthermore, participants may deny depressive symptoms
believing that the symptoms may negatively reflect their
adequacy as mothers. Because the study is retrospective,
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 Pittman Hernández DA. (2016) The association between maternal self-report of depression and the risk of pre-eclampsia:
outcome data from 960 participants in a retrospective case-control study. Evidence Based Midwifery 14(3): 76-81
we cannot guarantee that the survey tool would accurately
assess depression through the lens of the experience that these
women have encountered during their pregnancies. Recall
bias regarding medication use, such as antidepressants during
pregnancy, may also be present as women who experienced
PE may be more likely to recall this information than women
who endured an uneventful pregnancy. Research shows that
20% of critical details of an event are irretrievable after one
year and 50% are irretrievable after five years (Bradburn et
al, 1987).
Another important factor to consider is that the
membership of the Preeclampsia Foundation is not
representative of women with PE in general, and those
whose lives have been affected by this condition may have
joined the foundation because of an adverse outcome; this
may bias their recall. Additionally, this voluntary study does
not constitute a random population because the invitation
to participate was forwarded to family and friends that
mostly comprised of white, Hispanic and non-Hispanic
respondents. Despite the limitations to this study, the large
number of participants (960 women) provides enough data
to support the hypotheses that depression prior to and
during pregnancy is associated with increased PE rates. The
findings from this study indicate the importance of screening
pregnant women for depression at every obstetrical visit.
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76-81_EBM_122 Pitman.indd 81
Conclusions
It is known that PE is a very serious pregnancy-induced
condition affecting over four million women worldwide
and responsible for approximately 76,000 deaths each year
(Lyall and Belfort, 2007). Despite the wealth of literature
that investigates it’s clinical manifestations, there is still
no predictive test that can be used to identify women who
will subsequently develop PE. The mechanisms that may
link depression, specifically a history of MDD prior to
pregnancy, with an increased PE risk were unknown. This
work had been studied little elsewhere. Furthermore, the
clinical use of detecting depressive symptoms prior to and
during pregnancy to simultaneously predict the risk of PE
was unheard of.
Through this study, a positive association between MDD
prior to and during pregnancy with subsequent PE outcomes
was found. Future screenings are needed to detect depressive
symptoms in early pregnancy.
The findings from this present study highlight the
importance of doctors working with their patients more
closely in monitoring MDD during pregnancy. Only by
understanding the pathological mechanisms of PE can future
implications become developed for therapeutic solutions,
especially if the means to screen for MDD are readily
available today.
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81
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